Indian subcontinent, diverse though in many respects, has a common systematized cultural mechanism to cope with loss. What is unique about Hindus is their belief in reincarnation and the concept of karma. Writing Living Will (LW) or the Advanced Directive, I thought, was a brilliant idea to guide families to deal with the end-of-life situation of their loved ones. I enthusiastically advised my elderly colleagues in various forums to write the LW, lest had I predicted any negative fallout of this deed. I describe below the heated debates due to LW within the bereaved families. In both cases, the families argued that the reincarnation and transmigration of the soul cycle would be interrupted by not cremating the dead. Some instructions left in the LW were at variance with the traditional practices that created potentially explosive situations in the cases I describe below. Most contentious directive was no cremation and postdeath rites and rituals that created conflict of ideology and moral dilemma for the children. The author wants to share the latter with readers and stimulate discussion. Mourning and traditional grieving is encouraged in many cultures; can this not tantamount to systematic grief therapy? In many cultures, grief, and bereavement, through ages, have inspired renowned poets and scientists to express their viewpoints.

Keywords: Advanced directive, funeral rites, living will

How to cite this article:Dhadphale M. The living will, cultural aspects of death, and mourning rituals. Ann Indian Psychiatry 2018;2:47-50

During our social gatherings, my octogenarian friends often debated the controversial issue of voluntary euthanasia and matters related to death. And what after death? Some years ago, in one such meeting, I had discussed with them the concept of Advanced Directive or the Living Will (LW). They were disappointed with my talk, as I did not delve into the subject close to their heart, the voluntary euthanasia. Nevertheless, the concept of LW generated an unusually curious and interesting debate. Mainly for two reasons: One, it is a novel concept pertinent to the terminal care and end-of-life issues and two, the concept of “LW” was morally and socially acceptable idea.

Before writing the LW, I told them that one ought to be compos mentis. One writes LW to communicate their desire to the family or doctor. In this deed, you state inter alia your wish about care, “in the tragic event of you developing an irreversible condition and are unlikely to return to the pre-illness quality of life, or end up in a persistent vegetative state.” One person wrote in his LW that he should not be resuscitated; another wished not to remain in prolonged ICU care. The elderly have honestly worked hard during their lives and made provision for old age, metaphorically called the old age nest. The concept is not to live in a vegetative state and be a burden on the children. They are frightened to imagine their hard-earned assets disappear in hospital bills, while only prolonging their existence. Many knew about the satire about the evil vaidya (doctor), who is accused of being the real brother of the Lord Yama (the Lord of Death). It further taunts that Lord Yama only takes away the one's life (prana) but the Vaidya takes away his life and the wealth too! (Lord Yama only takes away one's life but the Vaidya depicted as Yama's real brother takes away both his life and the wealth) Senior citizens consider leaving inheritance however moderate to the family as the sacred and final duty.

The older generation (age 70+) does not view the death as either a tragic or final event, but an inevitable one, only one of the stages in the kalchakra the wheel of life–death–reincarnation and so on. Most of them remember seer Adi Shankaracharya's [1] elucidation of the concept of the cycle of life and death. He had preached that life and death must inevitably continue in perpetuity. More importantly, the seniors in my audience were familiar with teachings of the Holy Gita, regarding the death and reincarnation. From Lord Krishna's sermon to Arjun, the most renowned verse is “the death of a body is nothing more than shedding old clothes, the atman sheds the old clothes and dons the new ones.”[2] The conclusion at one meeting of the elders was that once the quality of life is compromised, you have fulfilled all your moral and spiritual duties, is it not the time to go? They pray that the doctors should not interfere with the process of natural death. Most of the elderly carefully considered the notion of LW and planned to write advanced directives.

Many wrote not only regarding the terminal care, i.e. no resuscitation/ventilator but also added that after death their bodies or useful organs be donated to the needy. Others forbid the children from traditional mourning or performing postdeath religious rites. During the last 3 years, members of two bereaved families have challenged the validity of LW as well as the instructions.

In one case, the deceased had directed his son not to cremate but donate the body to a medical school. He was livid with his dad's perplexing instructions in the LW. The son was a practising Hindu and an erudite Vedic scholar. He feared serious repercussions for the transgression (mahapaap), unless the dad was cremated and traditional rites performed. He argued when one is dead, the body belongs to the family, and they would deal with the situation according to their belief system. How could one no longer alive dictate about cremation and rituals? Is it not the moral duty of survivors to follow the traditions? Lest they would be inviting divine wrath for dereliction of son's duty. Not only did he fear for himself but also for his children. None in the family would be safe he was convinced, due to the infringement of the family traditions (samsara). He did his duty.

Six weeks later, as a family friend and a witness to his father's will, he sought my advice about the righteous way out of this labyrinth (chakrawyuha). Ibelieve we (psychiatrists) should not be judgmental and refrain from giving a verdict. My response was “one should do what appeals to their conscience.” Nevertheless, “talk with other family members” I added for political correctness. “Violation of the rituals dictated in the shastras (scriptures) would be nothing but profanity or sacrilege,” he told me. Further, he enlightened me on the transmigration of atman and its eventual desired emancipation from reincarnation (moksha). Pythagoras (582–500 BCE), the great Greek philosopher, he added, also believed in the transmigration of the soul. In recent times, he asked, what was our first prime minister's last wish? He did not wait for my response. But continued, the late PM wanted him cremated, further his ashes be immersed in the holy rivers and dispersed over the soil of the motherland. Most Hindus, he assured me, also aspire the same; hence, Indians passionately want the cremation and rituals that follow. He educated me on the latter. The rituals, he added, are full of symbolism and allegory. They tell you about death, emancipation of the soul, and reincarnation. In passing, he had also touched on the concept of death anniversary (shraddh). I thanked him for illumining me. Perhaps, grieving for soul may help him cope with the loss; I understood his guilt feelings and anxiety over the inevitable divine reprisals that may befall on the family in case he did not cremate dad. As a family friend rather than a psychiatrist, I advised him “to listen to his conscience and do his duty (karma).”

Long before I could recover from the vexatious cultural issues and ethical dilemma around the LW, I was confronted with similar contentious situation. Another friend passed away; in his LW, he forbid cremation and rituals. The poser, in this instance was, what action would you advise, if the children have conflicting ideas? He had a daughter and a son. The latter was in the US at the time of father's death, but the daughter lived in the same city and looked after dad during his final days. When informed of the sad demise, the son told the sister that he would not visit India; as per dad's LW, rituals were not to be performed. He would visit later at his convenience. The sister and other members felt stunned by his incredibly “cruel reaction!” They felt they must perform their moral and spiritual duty to respect the departed soul. They ought to do the right thing. They went ahead with the funeral, and the daughter, in the absence, of the son, lit the funeral pyre. She did so by disregarding the brother's objection and vehemently defended her action. She was convinced that she had performed her most sacred and pious duty to dad's atman. The other family members wholeheartedly supported and praised her action. The family concluded, “the western culture does not understand our sentiments, obligations (karma), and emotions towards the dead?” The family did not forget to berate the son and added, nowadays many “Europeans and Americans” also opt for cremation.

A few months later, during his visit to India, the son asked me, whether he could have done anything to prevent cremation as per his dad's wish? My response to his query was at best academic and at worse pedantic. “The LW is not really a legally defendable deed.” I told him to his dismay. I felt sorry for him, as all family members were hostile to him. They had ridiculed him for his insensitivity to his dad's demise.

Perusal of various available printed forms[3] for making a LW, none mentions the postdeath events or performance of religious rites. In the West, this is not a significant issue. To most of us in India, mourning and the postdeath rites is a norm and an obligatory duty. Death is not the real end of life; the life continues in perpetuity! In short as for LW, are we not on terra incognita? Another point, I often deliberate in my mind, whether nonperformance of traditional mourning and postdeath rites, leads to severe grief reaction? I believe, mourning rituals are therapeutic and systematized way of resolving grief. Perhaps, this is a subject of future research.

In the West, Colin Murray Parkes has written several books and papers on this subject. As a student, I enjoyed listening to his graphic description of grief reactions.[4] Asian and Western literature is replete with sentiments around loss/death. During my long experience in Eastern and Central Africa, the bereaved families consider traditional mourning as a sacred duty of paying respect to the departed soul.[5]

Were poets in the 19th century not inspired by the “Living, Sorrow, Grieving, and Death?” If grieving does not have any protective value, why did poet, Lord Tennyson (1809–1892) write his renowned poem, first rhymed stanza is thus:[6]

Home they brought her warrior dead She nor swoon'd nor utter'd cry.

All her maidens, watching said:”She must weep or she will die…

W H Auden, another contemporary poet, cleverly addresses this issue in “Funeral Blues.”[7] Where do people go to when they die? Children often ask this question, poet Jeanne has the answer, “they simply set up homes inside our dreams.”[8]

Comments

Although not yet on the statute book, the LW is a step in the direction of passive euthanasia. It needs to be publicized by us who are the torchbearers in preparing people for terminal events. In a comprehensive document on “End of life care policy: An integrated care plan for the dying,” deals with several relevant issues but two recommendations are relevant to the subject in this paper: 1. Empathic professional and 2. Setting up of bereavement care support facility.[9] Almost twenty years ago Huigol quotes, in his article, a comprehensive draft of bill on ichhamaran (euthanasia) by Colabawala.[10] It stipulates rigorous conditions to be satisfied before writing the LW. An important caveat allows the physician to opt out of terminal care, should it be against his conscience or the faith. The bill will also give legal immunity to the physician. A revolutionary and much-needed legislation: will it ever understand something clearly at the end of the day? Recently, the Supreme Court of India has granted permission on passive euthanasia in another case;[11] they had earlier granted permission in famous case of nurse Shanbaug in 2011;[12] both subjects were in persistent vegetative states. I predict, in our culture, unanimity or deciding on policy on passive euthanasia may albeit be impossible.

The writer of the LW should restrict themselves about the end-of-life situation and leave the rest to the discretion of the loved ones. The family may have no issue with the last wish of the late ancestor but should they (family) not have discretion as per family tradition? In India, the elderly do not fear death; as it is not the end. It is an inevitable stage in the cycle of death, birth, and rebirth that will continue in perpetuity. Having performed their mortal duties, they want a dignified and honorable exit. The LW is an instrument to facilitate that objective. Traditionally, we pray for painless death, without becoming helpless and dependent on anyone (Grand me peaceful death, not having to depend on anyone and your closeness till my last breath..).

In his scholarly presidential address, Shiv Gautam [13] quotes copiously from the Holy Gita and recommends anecdotes as psychotherapy for the dying person. Doctors and care workers often opt for “prolonging the life.” A frank debate among the carers and the LW writer should facilitate a decision-making procedure to protect all involved from guilt feelings. Start, the “end of life conversation,” advises Gawande that may assist the carers in making right decisions.[14] This would include guidance on writing LW. Our profession could advise health carers about the care of terminally ill.[9] At present, neither the LW nor voluntary/involuntary euthanasia has the legal sanction. (The Supreme Court of India is dealing with this issue.)

Legality of voluntary euthanasia is an enigma to my octogenarian friends. Death indeed is inevitable and natural event? Many lament the rising longevity as the problem. On a happy note, they often say “fifty years ago Yam raj (the Lord of death) came calling well before you were ready, now you wait!”

Finally, I often imagine, whether observance of traditional postdeath rites could prevent serious grief reactions among the bereaved and possibly prevent intense anniversary reactions? The postdeath rites/rituals can be interpreted as a form of systematized grieving process. Would nonperformance of cremation and the mourning rituals (immersing the ashes in the holy rivers) that follow not encourage the family of the deceased to recover from the loss of their dear one? I was unable to locate any literature on this topic. I admit that on a purely anecdotal level, the present author's long experience in rural Africa suggests it is the sacred duty of a family member to attend the funeral of their dear ones. Failure to do so, they (who did not attend) develop guilt feelings and features of depression. Hence, funeral leave is always granted, and traditionally, the bereaved are encouraged to grieve.[5] If one violates the family code, vis-à-vis funeral, the bereaved may have higher psychiatric morbidity? Perhaps, a subject for future research.